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      Journal of Pain Research (submit here)

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      Spontaneous Fusion After Cervical Disc Arthroplasty: A Case Report and Literature Review

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          Abstract

          Objective

          To report a rare case of spontaneous fusion (SF) following cervical disc arthroplasty (CDA), to review the related literature, and to propose a new measure to prevent it.

          Methods

          The course of a patient with SF is described here. The potential causes, risk factors, and preventive measure of SF after CDA published in previous studies have also been reviewed and discussed.

          Results

          A 63-year-old man presented with a 6-month history of progressive neck pain and developed left C-7 radiculopathy 4 years ago. Magnetic resonance imaging revealed disc herniation at the C6–C7 levels resulting in compression of the left C-7 nerve root. The patient underwent CDA at the C6–C7 levels, during which a PRESTIGE cervical disc device was implanted. He failed to follow-up regularly as recommended postoperatively because he was completely free from the pain in his neck and left upper limb. Four years later, he was readmitted with a 2-month history of occasional neck stiffness. Plain radiographs indicated complete radiographic fusion of the C6–C7 levels with trabecular bone bridging surrounding the cervical disc prosthesis, and dynamic imaging showed no motion. He was seen at regular follow-up visits for up to 60 months without special treatment, as his symptoms of neck stiffness were minor and his symptom has not worsened since then.

          Conclusion

          SF after CDA is a rare condition that can be attributed to patient- or prosthesis-related causes, and its risk factors are diverse. SF after CDA did not affect the patient’s clinical outcome, and no special treatment was required for it. Practitioners should be aware of this rare complication and advise patients of the risks before performing CDA.

          Most cited references27

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          Classification of heterotopic ossification (HO) in artificial disk replacement.

          There is currently no structured classification system to quantitate heterotopic bone formation after artificial disk replacement procedures. The purpose of this work was to develop a method of classifying heterotopic bone formation that is reliable between investigators with different levels of training and easy to remember with only five gradations of severity. One hundred one radiographs of clinical patients and 17 microradiographs from nonhuman primates having undergone various types of disk replacement were classified by seven independent reviewers. The kappa statistics were calculated for interobserver variation between the seven participants with various levels of spinal training and the intraobserver error based on two assessments made at least 2 months apart. The interobserver reliability correlation coefficient for seven raters calculated using the intraclass kappa correlation coefficient and the Kish rho was r = 0.9683 (P < 0.0001). The intraobserver reliability based on readings at two time intervals at a minimum of 2 months apart was r = 0.8949 (P = 0.01). This classification of heterotopic ossification, periannular calcification, and ectopic bone formation associated with total disk arthroplasty proved to be highly reliable and reproducible.
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            Heterotopic ossification in total cervical artificial disc replacement.

            Prospective clinical study enrolled in 2 centers (Munich and Liberec) as part of a prospective European multicenter study with ProDisc C (Synthes Inc., Paoli, PA). The first goal of the study was to evaluate the rate of heterotopic ossifications identified with plain radiograph following total cervical disc replacement (TCDR). The second goal was to show whether segmental motion can be preserved, and whether TCDR can provide improvement of the patient's ability to perform activities of daily living as well as a decrease of pain. Only a few reports about the radiologic outcome after TCDR are published so far. Heterotopic ossification is a well-known phenomenon after total hip arthroplasty. The rate of heterotopic ossification following TCDR is unclear. The radiographs of 54 patients (in total, 77 implanted prostheses) were analyzed 1 year after TCDR with a ProDisc C prosthesis. We classified the heterotopic ossification in 5 grades according to a recently published classification system for lumbar total disc replacement. For clinical parameters, the visual analog scale and the Neck Disability Index were evaluated preoperatively and 1 year postoperatively. The Student t test and Wilcoxon test were used for statistical analysis. In 26 treated segments (33.8%), no heterotopic ossification was detectable. Grade 1 ossifications were present in 6 levels (7.8%). A total of 30 segments (39.0%) showed grade 2 ossifications. Heterotopic ossifications that led to restrictions of the range of motion were present in 8 cases (10.4%). One year postoperatively, 7 cases (9.1%) had a spontaneous fusion of the treated segment. The clinical parameters improved significantly and were similar to previous reports about TCDR. Only 33.8% of the patients did not show any signs of heterotopic ossification, and the rate of spontaneous fusion after TCDR 1 year after surgery was unexpectedly high. There were 49.4% of the patients with grade 2-3 ossification, which lets us suspect an even higher rate of spontaneous fusion after long-term follow-ups. Motion preservation after TCDR is only guaranteed if spontaneous fusion can be prevented. Thus, mobility of the implanted segments needs to be further studied.
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              Clinical significance of heterotopic ossification in cervical disc replacement: a prospective multicenter clinical trial.

              Heterotopic ossification (HO) is a well-known complication in joint replacements, but its occurrence and clinical effect on cervical artificial discs has not yet been studied. The purpose of this study was to investigate the incidence of HO in cervical disc replacement, to identify any associated risk factors for HO, and to examine the relationship of HO with clinical outcomes. The patient data for this observational study were obtained from the original Bryan Disc Study by the European Consortium. Occurrence of HO was defined by the McAfee classification on the cervical lateral x-rays at 12 months after surgery. Secondary outcome measurements included Odom's criteria and the Medical Outcomes Study Short-Form 36-Item Health Survey. Sixteen (17.8%) of the 90 studied patients experienced HO, and 6 (6.7%) of these patients experienced Grade 3 and 4 HO. Ten patients' (11%) artificial discs were shown to have movement of less than 2 degrees on flexion and extension cervical x-ray at 12 months, with 4 of these patients having HO of Grade 3 or 4. Male sex (chi2 = 4.1; P = 0.0407) and older patients (P = 0.023; odds ratio = 1.10; 95% confidence interval = 1.01-1.19) were associated with development of HO. There is a strong association of the occurrence of HO with subsequent loss of movement of the implanted cervical artificial disc. We have found that sex and age are two possible risk factors in the development of HO after cervical disc replacement.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                JPR
                jpainres
                Journal of Pain Research
                Dove
                1178-7090
                21 April 2020
                2020
                : 13
                : 771-776
                Affiliations
                [1 ]Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University , Xi’an 710054, Shaanxi Province, People’s Republic of China
                [2 ]Department of Ophthalmology, Xi’an Fourth Hospital , Xi’an 710004, Shaanxi Province, People’s Republic of China
                [3 ]Department of Trauma Orthopedics, Honghui Hospital, Xi’an Jiaotong University , Xi’an 710054, Shaanxi Province, People’s Republic of China
                Author notes
                Correspondence: Qin-Peng Zhao; Ding-Jun Hao Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University , No. 555 Friendship East Road, Beilin District, Xi’an710054, Shaanxi Province, People’s Republic of China Tel/Fax +86-29-62818374; +86-29-87894724 Email hhyyjzwk@126.com; haodingjunspine@126.com
                [*]

                These authors contributed equally to this work

                Author information
                http://orcid.org/0000-0002-4409-688X
                Article
                242646
                10.2147/JPR.S242646
                7183536
                03dcf5fd-1192-4353-8134-aef58fa05820
                © 2020 Ge et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                History
                : 17 December 2019
                : 03 April 2020
                Page count
                Figures: 5, References: 34, Pages: 6
                Categories
                Case Report

                Anesthesiology & Pain management
                adjacent segment disease,cervical disc arthroplasty,spontaneous fusion,heterotopic ossification

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